A. Periodontal Disease
The two major diseases of the oral cavity are dental caries, a disease process by which cavities are produced in the tooth surface, and periodontal disease, a process in which the bone and soft tissues supporting the tooth are destroyed. Periodontal disease is a very common occurrence affecting, at a conservative estimate, between 70-90% of the world population and is the major cause of tooth loss in people over 35 years of age.
Periodontal disease is an all-inclusive term for a variety of clinical conditions that are forms of either gingivitis or periodontis. Gingivitis is an inflammation of the gingiva (or gums) that can be associated with poor oral hygiene and/or the hormonal state of the patient. It is believed that gingivitis, if untreated, will develop into periodontis. Periodontis is a bacterial disease in which the infection has progressed to involve the oral tissues which retain the teeth in the jawbone. Periodontis, if untreated, will eventually result in the loss of the affected tooth.
Although dental caries may be effectively treated with a combination of proper hygiene and fluoride, periodontal disease is often more refractile to treatment. This difference in amenability to treatment reflects the markedly different environments of the oral and periodontal cavities. The oral cavity is essentially an aerobic environment, which is constantly perfused by saliva. In contrast, the periodontal microenvironment is more anaerobic and is perfused by a plasma filtrate, known as the "gingival crevice fluid." The growth of microorganisms within this microenvironment has been shown to be the cause of periodontal disease (Loe, et al., J. Periodontol. 36:177 (1965); Slots, Scand. J. Dent. Res., 85:247 (1977); Socransky, S.S., J. Periodontol. 48:497-504 (1977); Axelsson, P., et al., J. Clin. Periodon. 5.133-151 (1978)). Hence, the treatment of the disease is directed toward controlling this growth. As the periodontal disease becomes more established, the periodontal microenvironment becomes more anaerobic and the flow of gingival crevice fluid increases. An excellent review of periodontal disease, and the methods for its treatment, is provided by Goodson, J.M. (In: Medical Applications of Controlled Release, Vol. II, Applications and Evaluation (Langer, R.S., et al., Eds.), CRC Press, Inc., Boca Raton, Fla. (1984), pp. 115-138), which reference is incorporated by reference herein.
Efforts to treat periodontal disease have been impeded by several factors. Because the site of the bacterial infection is largely inaccessible to agents present in the oral cavity, antimicrobial agents provided to the oral cavity are generally ineffective. The increased flow of gingival crevice fluid, which accompanies periodontal disease, has the effect of diluting and removing therapeutic agents placed within the periodontal crevice. Systemic administration of antibiotics has been shown to be a useful method of controlling the subgingival flora (Listgarten et al., J. Clin. Periodont. 5:246 (1978)), however discontinuation of therapy is often associated with the return of the potential pathogens to the pockets. Systemic administration, therefore, has had only variable success in treating periodontal disease (Genco, R.J., J. Periodontol. 52:545 (1981)). Long-term antibacterial therapy has been used, but the potential dangers associated with this form of treatment, which include the development of resistant strains and super-imposed infections, do not warrant its serious consideration. Antibacterial agents such as chlorhexidine and quaternary ammonium salts in the form of mouth rinses have proved to be successful in preventing periodontal disease (Loe et al., J. Periodont. Res. 5:78 (1970)). These agents, however, are unable to affect the subgingival flora when administered in this form as they do not penetrate into the pockets which are the result of the disease. Hence, they cannot be used in mouth rinses to treat an established periodontal disease.
Patient acceptance has significantly limited the utility of non-pharmacological treatments of periodontal disease. The most widely used non-pharmacological approach to date has been mechanical cleaning methods combined with surgery. Although this method has proved to be fairly successful in treating individuals, there is still a high recurrence rate. There is also the problem of motivating people to good oral hygiene habits that they will maintain throughout their lives.
B. Use of Sustained-release Pharmaceutical Compositions in the Treatment of Periodontal and Other Diseases
In response to the importance of treating periodontal disease, and the failure of conventional control therapies, researchers have developed control-release pharmaceutical compositions which are capable of being inserted into the periodontal cavity and of slowly releasing an antimicrobial agent. Goodson et al. (J. Clin. Periodont. 6:83 (1979); J. Periodont. Supp. - Special Issue 81-87 (1985)) proposed the use of a device that could be placed within the pockets and that would provide a sustained release of antibacterial agents to control the pocket flora. The system they described released the drug for up to 10 days. It appeared to cause marked changes in the pocket flora. The most investigated systems for controlled release comprise incorporating such a drug into a polymeric matrix, which is then shaped into a convenient form and implanted into the periodontal cavity.
Ethyl cellulose has been successfully employed as a polymeric matrix of a periodontal implant (Friedman, M., et al., J. Periodon. Res. 17:323-328 (1982); Soskolne, A., et al., J. Periodon. Res. 18:330-336 (1983); Stabholz, A., et al., J. Clin. Periodon. 13:783-788 (1986)). Various antibacterial agents, such as chlorhexidine, metronidazole, iodine, cetyl puridinium chloride, have been incorporated into such ethyl cellulose films. Loesche, W.J. (U.S. Pat. No. 4,568,535) discloses the use of periodontal implants composed of ethyl cellulose which contain metronidazole in the treatment of periodontal disease. Although such films were found to be effective in treating periodontal disease, their non-biodegradable nature required their removal after the conclusion of therapy.
The usefulness of silicon rubbers as an implant material is well established (Folkman, J., et al., Ann. N. Y. Acad. Sci. 111:857 (1964)). However, even though such polymers are well tolerated by the tissue and are useful for a variety of drugs, their suitability as implants is seriously limited because the device must be surgically removed after use. Hence, a major therapeutic goal is the development of a biodegradable implant which would not need to be removed from the patient.
Degradable polymers and copolymers which have been substantially investigated as potential implant compositions include poly(lactic acid) (Kulkarni et., Arch. Surg. 93:839 (1966)), poly(glygolic acid) (Higgins, U.S. Pat. No. 2,676,945 (1954)), and poly(lactic acid)poly(glycolic acid) copolymer (Schmitt et al., U.S. Pat. No. 3,397,033 (1967)). The properties and uses of such polyamides and of copolymers of polyamides and polyesters have been extensively disclosed (Kurtz, French Patent No. 2,059,690 (1971); Kurtz, French Patent No. 2,059,691 (1971); Mori et al., Japanese Patent No. 72-43,220 (1972); Kurtz, U.S. Pat. No. 3,642,003 (1970)). The biodegradation of poly(lactic acid) and poly(glycolic acid) can require three to five months (Schneider, French Patent No. 1,478,694 (1967); Darkik, Am. J. Surg. 121:656 (1971)). Thus, it would not be preferable to employ implants composed of such polymers in situations where more rapid biodegradation is desired.
Absorbable periodontal implants have been described by Noguchi, et al. (Bull. Tokyo, Med. Dent. Univ. 31:145 (1984)), which used a hydroxypropylcellulose polymer. Suzuki, Y., et al. (U.S. Pat. No. 4,569,837) discloses the use of water-soluble polymeric substances (such as methyl cellulose, gelatin, etc.) as a polymeric matrix for a periodontal implant.
Pharmaceutical compositions containing gelatin have been described by Lieb, H., et al. (U.S. Pat. No. 2,961,374) and by Easton, I.A. (U.S. Pat. No. 4,344,967).
Despite the existence of the above-described sustained drug release compositions, a need still exists for a biodegradable sustained-release composition which is capable of delivering a pharmacological composition for a period of time sufficient to treat a periodontal infection.